The Next Step - Veterinary Specialist Group

ISSUE 24 OCTOBER 2012
The Next Step
EXPERTISE
:
TECHNOLOGY
:
C O M PA S S I O N
Australian and New Zealand College
Science Week
By Mike Coleman
This year was a big year for Mike Coleman at the College Science
Week. As well as being a Small Animal Medicine Fellowship
examiner, Mike also had a lecture to prepare on bronchoscopy for
the science week programme. On top of this he is currently the
Small Animal Medicine Chapter President which brings with it a whole
lot of other responsibilities. It was hard work, but things generally
went smoothly.
For those of you who don’t know, the Australian and New Zealand
College run a conference every year on the Gold Coast in the middle
of winter. It is a great place to go to escape the wet and cold for a
time! The conference is generally aimed at a higher level than most
conferences in Australia and New Zealand. This year was no exception
with a very high calibre of speakers.
For those of you who weren’t there here is a summary of what was
covered in the bronchoscopy lecture.
BRONCHOSCOPY
Indications
Bronchoscopy is a valuable tool for investigating cats and dogs with
both acute and chronic coughing, stridor, dyspnoea, haemoptysis,
abnormal respiration and exercise intolerance. Bronchoscopy is used
for visualising airway collapse, neoplastic and non-neoplastic masses
of the larger bronchi and trachea and foreign bodies. Targeted biopsies
and lavage can then be done. A bronchoalveolar lavage (BAL) using a
bronchoscope results in a better cell yield than when done ‘blindly’.
Therapeutically bronchoscopy can be used to remove foreign bodies
and mucus plugs. It may be used to guide the placement of tracheal
stents for collapsing airway, although fluoroscopic guidance for this is
most common. A recent case series described bronchoscopic debulking
of tracheal carcinomas in three cats. As well as being able to examine
the trachea and larger bronchi, examination of the nasophyarynx and
larynx can be easily performed during the same procedure.
Equipment
For cats and small dogs a small diameter (e.g. 5-6mm) flexible
scope is required. These have a ‘multi-use’ biopsy channel –oxygen
administration, passing biopsy forceps and saline for BALs. Tip
motion is in one plane only e.g. up or down. A gastroduodenoscope
can be used in larger dogs. While rigid scopes can be used complete
examination and obtaining good BAL samples will be much more
difficult. Other equipment includes biopsy forceps, cytology brushes,
foreign body retrieval forceps and tubing.
Anaesthesia
Often animals that are candidates for bronchscopy have compromised
respiratory function. A ‘risk-assessment’ needs to be made – do the
benefits of a diagnosis outweigh the risk of the procedure. I do not
have a set anaesthetic protocol, each case is treated individually.
Having said that some general guidelines are:
- Preoxygenation for 10-15 minutes before induction is important.
This allows for a longer induction period before the animal becomes
hypoxic. I use a facemask in dogs, and an oxygen tent in smaller
dogs and cats.
- If laryngeal paralysis is suspected then a light plane of anaesthesia
is required to examine the larynx. Careful titration of propofol is my
choice in this situation. The dog needs to be taking reasonably deep
breaths to evaluate laryngeal function accurately. The injectable
respiratory stimulant doxapram can be given to aid the diagnosis.
continued on page 3
EXPERTISE
:
TECHNOLOGY
:
C O M PA S S I O N
PAGE 1
A new way to manage feline
hyperthyroidism
Breakthrough nutrition
Clinically proven to help
manage thyroid health1,2,3*
Limited iodine reduces
excess thyroid hormone
production1,2,3*
Complete diet for adult
cats that need restricted
iodine intake 2
Great taste that cats love
*When fed as the sole source of nutrition
NEW
For use only under veterinary supervision
Clinical Nutrition to Improve
Quality of Life™
Registered Pursuant to the ACVM Act 1997, No. A10797, A10800.
References: 1.Controlled level of dietary iodine normalized serum total thyroxine in cats with naturally occurring hyperthyroidism.
Yu S, Wedekind KJ, BurrisPA, et al. J Vet Intern Med 2011; 25:683-684 (abstract) 2. Titration of dietary iodine for reducing
serum thyroxine concentrations in newly diagnosed hyperthyroid cats. Melendez LD, Yamaka RM, Forrester SD, et al. J Vet
Intern Med 2011; 25:683 (abstract). 3. Titration of dietary iodine for maintaining normal serum thyroxine concentrations in
hyperthyroid cats. Melendez LD, Yamaka RM, Burris PA. J Vet Intern Med 2011; 25:683 (abstract).
©2012 Hill’s Pet Nutrition (NZ) Ltd. ™ Shown are trademarks of Hill’s Pet Nutrition, Inc. DS/NZ/Mktg/Jun2012. HNZ2004NS. 06/12. GHG.
Nutrition is therapy.
Talk to your clients today.
Australian and New Zealand College Science Week
- Laryngeal obstruction or collapse can make intubation very difficult.
It is good to be prepared beforehand with a laryngoscope, various
ET tube sizes and even equipment for an emergency tracheotomy
if required.
- Remember cats can laryngospasm very easily, application of topical
lidocaine is important. Topical lidocaine can also be sprayed into
the trachea to reduce the cough reflex in both dogs and cats.
- In smaller dogs and cats it is not possible to pass the bronchoscope
through the ET tube. Repeated extubation and intubation is
required. Be as gentle as possible as inflammation and swelling of
the laryngeal region will make both intubation and recovery more
difficult.
- I always intubate the animal first and use isoflurane to reach a
good, relatively deep plane of anaesthesia before starting the
procedure.
- Oxygen can be administered through the biopsy channel of the
bronchoscope while the animal is not connected to the anaesthetic
machine.
- Often repeated doses of injectable anaesthetic are required during
the procedure.
Technique
It is important to be both quick and thorough with the examination,
particularly in small animals when the scope may be occluding most
of the airway. I have two people assisting me, one to be constantly
monitoring the patient and the other to assist with sample collection.
Sternal or lateral recumbency can be used. Once the scope is through
the arytenoids I orientate the scope so the dorsal tracheal membrane is
at the top of the screen. This means the right mainstem bronchus will
be on the left of the screen and the left mainstem bronchus on the right
(see figure 1). A systematic approach makes returning to an abnormal
area for sample collection much easier. Once you meet resistance stop
advancing the scope, remember the view is smaller than the diameter
of the scope. Make a note of mucous membrane appearance, presence
of mucus, airway collapse, masses or foreign bodies.
Bronchoalveolar Lavage (BAL)
The tip of the bronchoscope is ‘wedged’ in a bronchus. Warmed sterile
saline is flushed through the biopsy port of the scope, or through a
sterile tube placed through the port. I use 5 ml aliquots in cats and
Figure 1: View of tracheal
bifurcation in a dog
Figure 2: Distal tracheal mass
obstructing tracheal bifurcation
in a cat
small dogs and 10-20 mls in larger dogs. The lavage is repeated several
times. A cloudy, frothy appearing fluid is ideal. Hypoxia following BAL
can occur and ongoing oxygen support may be required.
The retrieved saline is submitted for both cytology and culture for
aerobes, anaerobes and Mycoplasma. Normal cell counts in the dog
and cat are approximately 200 to 400 cells/ml. Cellular makeup 65% macrophages in the cat and 83% macrophages in the dog.
Neutrophils are around 5% of the cells in dogs and cats, lymphocytes
4% to 6%, mast cells 1% to 2 %, and eosinophils up to 25% in the
cat and 4% in the dog. Healthy animals can have positive cultures, so
interpretation of results in conjunction with radiographic and cytologic
findings is important.
Biopsy
Biopsy is most useful when there is a focal mass and differentiating
neoplastic disease from a non-neoplastic polyp is important e.g.
Figure 2. I have not had a lot of success with biopsies of an inflamed
looking bronchial mucosa. The samples are very small and often have
crush artefact.
References:
1) Johnson, et al. J Vet Intern Med 2007; 21(2):219. 2) Queen EV et al. J Vet Intern
Med 2010; 24(4): 990. 3) Tenwolde AC et al. J Vet Intern Med 2010; 24(5):1063.
4) Mercier E et al. Vet J 2011; 187(2):225. 5) Johnson LR et al. J Vet Intern Med
2011; 25(2): 236. 6) Heikkila HP et al. J Vet Intern Med 2011; 25(3): 433. 7)
Ettinger and Feldman (Eds) Veterinary Internal Medicine. Seventh Ed: 408, 1063.
8) Tams(ed) Small Animal Endoscopy Second Ed: 377 8) Amis et al. Am J Vet Res
1986: 47:264
Keep up to date with all the latest news from
VSG including up and coming events by
going to our web site www.vsg.co.nz which
will direct you to our Facebook page.
EXPERTISE
:
TECHNOLOGY
:
C O M PA S S I O N
PAGE 3
David Letterman’s Top 10 Tips
for Practising Better Internal
Bet you didn’t know that David moonlights as a veterinary Internal Medicine specialist in Lake Wobegon in the
USA. When he is not making jokes about American politicians and glad-handing the rich and famous he sees
patients and these are some pearls of wisdom he has learned in his long career...
10
Don’t do unnecessary bile
acid panels!
Assuming that no red cell destruction is happening,
an elevated bilirubin concentration on a chemistry panel is all you
need to know in order to deduce that liver function is poor. Bilirubin
elevation occurs subsequent to bile acid elevation as the latter test is
more sensitive. Performing a bile acid panel on a dog with increased
bilirubin and a normal haemogram is a waste of time and money;
just jump straight to an ultrasound examination to look for structural
liver disease. As with all rules there will be a very occasional case
where these parameters do not apply, but 99% of the time this
dictum is true.
9
You need a urinalysis to interpret
renal parameters!
Please always include at least a basic urinalysis
in your initial evaluation of a sick animal, or when doing preanaesthetic blood tests or geriatric checks. You simply cannot
interpret creatinine, BUN or phosphorus as indicators of renal
function unless you also know urine specific gravity. We all know
it can be frustrating to chase dogs around to collect urine and not
everyone is comfortable with cystocentesis, especially in dogs, but
that’s no excuse for ignoring this important part of the health profile.
I have lost count of the number of times a urine specific gravity done
after referral has changed the direction of an investigation into the
renal health of an animal.
8
Get a radiologist to read your chest
and abdominal films!
General practitioners have to utilize a wide range of
skills and I admire their all-round talents. They have to be surgeons,
anaesthetists, internists, dermatologists, dentists etc. However one
of the most difficult skills to keep on top of is that of reading chest
and abdominal films accurately. As an internist I look at hundreds
of chest and abdominal films every year and have the advantage of
standing next to a radiologist most of the time but Chris almost always
gets more information out of the images than I can. Radiologists
such as Chris and those at Massey offer a film reading service at a
very reasonable cost. I challenge you to try sending in half a dozen
chest/abdominal films from sick animals and see how much more
information you get from a radiologist than you had extracted from
the image yourself. Don’t be shy about your film quality, radiologists
are amazing at getting useful information from films that are less
than perfect.
THE NEXT STEP
PAGE 4
7
Get baseline bloods and urine before
you start fluid therapy or drugs in a
sick patient!
This would seem to be a no-brainer, but we see many patients where
therapies of various types were started before blood and/or urine tests
were obtained. Of course fluids, electrolyte supplements, steroids and
various other drugs will change the patient’s homoeostasis and make
it more difficult to interpret information that is obtained subsequent
to their use. Even if you do not intend to run bloods immediately it
is easy enough to send them to a lab with a ‘hold” on them so that
analyses can be done at short notice if required. This principle is
especially true in emergency clinics or at your general practice on a
Friday night or weekend where you may not have access to laboratory
service until Monday. Sequential analysis of the same parameter
(eg creatinine in renal failure) is vital for assessing the success of
therapy, and the results make much more sense if we can compare
back to unaffected baseline numbers.
6
Be aware of your ultrasound
limitations!
5
Blood test results are dynamic!
I always say that if ultrasound was taken away from me
I would stop practising. Almost every single patient I see will have an
ultrasound study of either the abdomen or heart or both. I long ago had
to concede that my colleagues in the radiology department at VSG can
detect far more with their ultrasound probe than I can with my fingers.
Ultrasound machines are popping up in more and more clinics and
Chris tells me that many practitioners are attending CPD courses to
learn ultrasound skills. This is all good, but a $30,000 machine and
a couple of weekend courses do not a specialist radiologist make. We
are seeing an increased number of patients where in-clinic ultrasound
studies have either sent a clinician on completely the wrong path
or have resulted in a partial picture leading to a significantly worse
outcome for the patient. Chris has a $300,000 machine and has done
thousands of studies so if your patient doesn’t seem to be responding
as your ultrasound study would lead you to believe then please refer
for either total case management or an outpatient ultrasound as you
see fit. This is also an ideal way of checking the quality of your work;
you can read the report from Chris or Mike and compare it with your
own results.
For a critical patient in a human hospital studies such
as chemistry panels and CBCs will sometimes be done
several times a day and more dynamic analytes such as potassium or
Medicine...
By Mark Robson
calcium can be checked 5 to 10 times per day. In veterinary medicine
there seems to be a belief that the blood results that were obtained
on the first of the month will still be applicable to that patient on the
30th of the month. In many instances in the medicine department
at VSG we make a diagnosis just by repeating tests that have already
been done and which were unremarkable the first time. It takes some
convincing to get owners to agree to this, but it’s amazing how the
changes in analytes such as ALT, creatinine, albumin, and potassium
can lead the clinician to a diagnosis and I always show the owners the
results to demonstrate in graphic form how things change. A single
blood test is like a snapshot of a garden, it represents one point in time
but you can be sure that the next day the image would be different.
4
Please don’t be too pessimistic about
cancer patients!
When I came back from United States in late 1996
there wasn’t a lot of cancer medicine happening in Auckland. I am
enthusiastic about cancer treatment and am always willing to give
treatment a go even in apparently hopeless cases as long as the
owner is willing, costs are explained, and we are choosing humane
options for the patient. The attitude to cancer treatment among
veterinarians has definitely improved in the last 15 years but I still
see too many patients who have reached us too late for optimal
treatment. Owners will sometimes find us without a recommendation
from their veterinarian, and in too many instances cancers that we
could have treated effectively are beyond hope because the general
practitioner gave a negative prognosis without fully understanding the
options available. No one can know everything about every aspect of
veterinary medicine. I try hard to keep up but I don’t know everything
about internal medicine so it’s impossible for a general practitioner to
comprehensively discuss many cancers with owners. My suggestion is
to offer referral for any cancer patient that is even slightly complicated
because you never know which owner is going to take up the offer and
want to give maximum effort to their pet.
3
Stay alert when using pancreatic
diagnostics!
The literature regarding amylase, lipase and the
various forms of pancreas-specific lipase is voluminous and somewhat
controversial. The advent of the SNAP pancreas-specific lipase tests
which can be used in-clinic is both a curse and a benefit. It is a quick
and easy test to perform, but like all diagnostic tests the accuracy
is dependent upon the incidence of the disease. If you have a sick
patient who is not showing signs consistent with pancreatitis then
the test will have poor predictive value and a positive result is more
likely to be wrong than right. Pancreas-specific lipase (or the routine
amylase and lipase testing you get on a chemistry panel) is not
intended for general screening of any animal that is ill, or for healthy
animals. The relatively high published sensitivity and specificity of
pancreas specific lipase applies to their use in the setting of a sample
A beautiful demonstration of colour Doppler imagery from a
portosystemic shunt patient; it takes excellent equipment and
extensive training and experience to be able to get images of this
type. Image courtesy of the Radiology Department at VSG.
population with clinical signs consistent with pancreatitis such as
vomiting, abdominal pain, anorexia etc. The less a patient looks like
he is suffering from pancreatitis the less accurate the testing is.
2
Be careful with thyroid testing!
1
If the owner asks for a test to be
done, do it!
The phenomenon of sick euthyroid syndrome
continues to be a hot topic in internal medicine circles.
I still see patients who were diagnosed with clinical hypothyroidism
based on a middling-low thyroid hormone result around 12 to 15.
Most internists don’t get excited about total T4 concentrations in
dogs until they are around five or below. We could talk all day about
this aspect of endocrinology, and I certainly support the use of TSH
concentration to back up a low thyroid reading, but diagnosing a dog
with hypothyroidism and starting thyroid replacement therapy based
on a concentration of 14 or 15 is highly dubious.
I have lost count of the number of diagnoses I have
made in referred patients by doing a diagnostic test that the owner
has been pestering the referring vet to do for some time. This might
be something simple such as a urine check, or might be more complex
such as a chest x-ray or ultrasound, but is rarely as complex as a
CT scan or endoscopy procedure. Owners are becoming more and
more educated and are quite happy to spend time on the internet
researching their pet’s problems. I would advise that if an owner asks
for a particular test to be done, and it is not harmful for the pet, then
go ahead and do the test even if it doesn’t necessarily seem logical
to you. Where is the harm? Even if the test appears to be irrelevant
you will make some income from it, a negative result will rule out a
disease, and you will make the owner happy. Too many times I have
seen the relationship between a client and their veterinarian come
to an end because I diagnose their pet by performing a test that the
client feels that the referring vet has ignored in the past. They ask
me “why didn’t my vet do that test when I asked him to?” I have to
respond; “you need to ask your veterinarian”. Unfortunately this is
often followed by a breakdown in the client-veterinarian relationship
and both parties lose out.
EXPERTISE
:
TECHNOLOGY
:
C O M PA S S I O N
PAGE 5
Camera Digitalized Images
for Teleradiology
By Chris Warman
The study compared the ability of veterinary
radiologists to interpret both analogue and
camera digitalized images with respect to
the accuracy achieved by private practice
veterinarians.
From the late 1990s through to the mid2000s we used a state-of-the-art late 1990s
digital camera to produce reproductions
of analogue radiographs for presentation
purposes. I, like most veterinary radiologists,
was happy enough with the quality of the
reproduction for teaching purposes but had
concerns as to whether the reproduction of
the original was of a quality good enough
for diagnostic interpretation. The use of the
macro feature of the digital camera could
to some degree reduce these concerns when
the second image was obtained featuring a
small area of interest. The overall feeling of
the majority of veterinary radiologists at that
time was whilst they could certainly identify
pathology on these images there were serious
concerns amongst this group on the validity
of this method of radiographic reproduction
for diagnostic purposes.
The Journal of Veterinary Radiology and
Ultrasound (November/December 2011),
recently reported a prospective study;
the first prospective study on this topic
to my knowledge in veterinary medicine,
although studies have been performed in
human medicine. This study shed new
light on the value of digital camera copies
of analogue radiographs for diagnostic
evaluation by a radiologist at a distance.
THE NEXT STEP
PAGE 6
Some human studies have found that
subtle lesions such as small pulmonary
nodules, fractures and pneumothoraces
may be missed on digitally copied analogue
images; however most studies have found
there is no significant loss in interpretive
accuracy. This recent article has revealed
similar findings, in that veterinary
radiologists’ accuracy did not significantly
differ between the original analogue image
and a camera-digitalized image. The
radiologists’ sensitivity was however higher
for analogue images. The radiologists’
accuracy and interpretation of digital and
analogue images was significantly better
when compared with private practice
veterinarians’ interpretation of the original
analogue image. The time to interpret any
diagnostic image, whether it be the original
analogue or camera digitalized image, was
also significantly reduced when a radiologist
was reading the image compared with a
primary practitioner.
Interestingly enough, the time taken by
a radiologist to evaluate a digital image
was significantly greater than the time
taken to interpret analogue images. This
latter finding is in line with a number of
studies that have been performed using eye
tracking software to evaluate radiologist
performance when interpreting diagnostic
images of different formats.
Camera digitalized images of the analogue
radiographs can certainly be a valid form
of teleradiology for clinics that do not
have digital radiography equipment. The
quality of the original image and the
level of expertise available to create the
reproduction image do have a significant
influence on the final quality of the
reproduction. It is also important when
using this reproduction method that both
the primary practitioner and the radiologist
appreciate that some lesions are going to
be missed on camera digitalized images
compared with the original analogue
radiographs. The overall decrease in
turnaround time of diagnostic images
and the timely radiologist’s input to the
case probably compensates for the small
number of cases in which some lesions are
not identified.
The improving quality of consumer digital
cameras should in the future be able
to minimize the number of these lesion
misrecognitions. Many good quality digital
cameras can now be bought for just a few
hundred dollars and the purchase of one
by a practice for the purposes of acquiring
images for teleradiology and other aspects
of telemedicine should be considered
an essential tool for the delivery of good
patient care.
In order to obtain good quality camera
digitalized images of analogue radiographs
it is essential to adhere to fairly strict
protocols in the reproduction process. I
have posted a technique on my website
www.vetrad.co.nz under Knowledgebase.
Cecil -
By Alastair Coomer
A Handsome Aucklander!
If there were a “Most Handsome Dog in New Zealand” award, my nomination would be Cecil. Many
would question this, but very few would question his nomination for the “Precariously Sick” award.
Cecil is a much loved, 12-year old male
Affenpinscher, that presented to his local
veterinarian with a 24-hour history of
lethargy and vomiting. His work-up revealed
icterus, with elevations in all liver enzyme
activities and bilirubin, normal PCV, and
normal indirect liver function tests (albumin
and glucose). To say that his liver enzyme
activities were elevated, was a bit of an
under-statement, and his initial results are
transcribed below:
ALKP - ##ERROR## (too high to
count) – reference 20-150 U/L
ALT 1717 – reference 10-118
Bilirubin 103 – reference 2-10
Even as a surgeon, I would start to get
excited by these values! Appropriately, and
importantly, Cecil was immediately referred
for an abdominal ultrasound with Dr. Chris
Warman. The ultrasound revealed an organized
and obstructive gall bladder mucocoele,
with severe focal peritonitis around the gall
bladder. These findings suggested possible
rupture of the gall bladder, and subsequent
bile peritonitis.
Cecil subsequently had his gall bladder
e
removed (cholycystectomy),
and the extrahepatic biliary obstruction relieved. Cecil
made a complete, rapid, and excellent
recovery from surgery. Thankfully for Cecil,
he recovered from being “precariously sick”
thanks to smart and urgent clinical decisionmaking. Unfortunately, many dogs do not
enjoy such a happy ending.
Gall bladder mucocoele is the consequence of
mucosal gland hyperplasia and hypersecretion,
in conjunction with compromised contraction
and motility of the gall bladder and cystic
duct. The exact pathogenesis remains
elusive, though it is thought to be influenced
by glucocorticoid excess (exogenous or
endogenous) and ascending bacterial
cholycystitis/cholangiohepatitis.
Unfortunately, both the presenting clinical
signs and the ultrasonographic appearance
of mucocoeles can vary greatly. At one
end of the spectrum are the dogs with no
clinical symptoms, and the mucocoele is
an incidental finding on Ultrasonographic
examination. These dogs likely have a good
prognosis (for their mucocoele) with or
without surgery, as long as the mucocoele is
treated, and frequently monitored.
At the other end of the spectrum, are the
dogs with extra-hepatic biliary obstruction
(EHBO) and/or bile peritonitis, secondary to
severe disease in their gall bladder and bile
ducts. The clinical consequences of EHBO
include pain, icterus, vomiting, maldigestion
of fats and subsequent malabsorption of fatsoluble vitamins. Malabsorption of Vitamin K
(in particular) can result in relative vitamin
K deficiency, and subsequent coagulopathy.
Reported mortality with surgical intervention
for biliary disease is 20 - 40%. At first blush,
these prognoses are terrible, but must be
interpreted with the following caveats:
1. These reports only included dogs with
EHBO or bile peritonitis i.e. the sickest of
the sick.
2. The mortality of dogs with complete EHBO
or bile peritonitis WITHOUT surgery, has
not been reported, but would approach
100%.
Recently, reports of “elective” cholycystectomy
to remove organized mucocoeles in dogs
with absent-to-moderate clinical signs, have
resulted in a dramatic decrease in mortality
e
to less than 10%. Further, cholycystectomy
has been shown to have little effect on
digestive function in normal dogs. This
suggestes that the prognosis for dogs
undergoing biliary surgery is entirely
dependent on the perioperative critical care.
Further, it also implies that their mortality
is related their systemic illness (peritonitis,
hypotension, pancreatitis, coagulopathy)
rather than their local (biliary) surgery.
Despite many surgical advances in
extrahepatic biliary surgery (including
natural orifice trans-gastric endoscopic chole
eycystectomy,
laparoscopic cholecystectomy,
automated sealing and stapling devices), I
EXPERTISE
:
prefer open-laparotomy surgery for the biliary
tract. Establishing the patency of the common bile duct is essential to a successful
surgical outcome. The common bile duct, and
cystic duct, are often occluded with mucinous
debris and can easily be inadvertently ligated
by inexperienced surgeons. Therefore, in my
hands, the only way I can be comfortable
that the extrahepatic biliary tree is patent,
is by feeling the duct and passing a catheter
through the “sphincter of Oddi”.
My approach to biliary surgery in dogs is:
- Whether the surgery is elective
(asymptomatic) or urgent, meticulous
surgical technique and 24-hour perioperative care are essential to a successful
outcome.
- While the consequences of “elective”
cholycystectomy are few, there are
some dogs that will not require surgery.
These dogs MUST be treated medically,
and closely monitored for resolution/
progression.
- Dogs that survive the early peri-operative
period, and are discharged from the
hospital have an excellent prognosis.
BUT, their underlying conditions must be
treated.
As this relates to Cecil, he has no evidence
of ongoing biliary obstruction, and he has
started treatment for concurrent Cushing’s.
If you see Cecil around Auckland, please
remind him how handsome he is!!
TECHNOLOGY
:
C O M PA S S I O N
PAGE 7
Quizzler
Contacts
DR. ALEX WALKER
Specialist in Small Animal Surgery
1. The mucosal surface of the stomach is characterized by folds, termed? (5)
[email protected]
2. The acetabulum is characterized by a depression known as the _____ / _____ (10 / 5)
DR. CHRIS WARMAN
3. Gas within the ____ / ____ can superimpose on the pelvis in ventrodorsal radiographs
creating focal radiolucency over the ischial plateau, which can be misinterpreted as a
lytic bone lesion. (4 / 4)
Specialist in Veterinary Radiology
[email protected]
Dr. Mark Robson
4. In lateral radiographs of the feline stifle it is often possible to find small mineralized
foci in the cranial aspect of the joint due to _____ ossification. (8)
Specialist in Small Animal Medicine
[email protected]
5. The flexed _____ image of the tarsus reveal the medial and lateral trochlea of the talus
with minimal superimposition. (12)
Dr. Richard JerRam
Specialist in Small Animal Surgery
[email protected]
6. Analog radiographs of the thorax are best obtained using a high _____ and low _____
exposure factors. (3 / 3)
Dr. MIKE COLEMAN
Specialist in Small Animal Medicine
7. Small sesamoid bone at the caudal aspect of the stifle. (9)
[email protected]
8. Term for absence of a digit. (8)
Dr. Robyn Gear
9. Medial deviation of limb distal to a fracture malunion. (5)
Specialist in Small Animal Medicine
10. Results in a so called “kiwi” pattern on sonographic examination? (7 / 8)
[email protected]
11. The _____ /_____ artery is the largest abdominal visceral branch of the aorta. (7 / 10)
Dr. ALASTAIR COOMER
12. COMS is an an acronym for c_____ o_____ m_____ s_____. (6 / 9 / 12 / 8)
[email protected]
13. A _____ unit is a measurement parameter used in computed tomography named after
an English engineer for his part in developing this diagnostic imaging technique. (10)
14. Osteosarcoma of the esophagus occurs secondary to transformation of a _____ / _____
granuloma. (10 / 4)
15. _____ syndrome results in a so called “Swiss cheese” appearance of the liver on
ultrasound. (15)
16._____ wave Doppler is used in echocardiography to evaluate high velocity flows within the
heart. (10)
17. In MRI the term FLAIR stands for? (6 / 10 / 9 / 8)
Specialist in Small Animal Surgery
97 Carrington Road,
Mt Albert, Auckland 1025
Phone: (09) 845 5455 Fax: (09) 845 5456
Email: [email protected] Website: www.vsg.co.nz
The Veterinary Specialist Group hospital
is located on the Unitec campus situated
between Gates 2 and 3 on Carrington Rd.
18. The surname of New Zealand flag bearer at the London 2012 Olympics. (6)
19. New Zealand’s final position on the Olympic medal table for the 2012 Olympics. (9)
Point Chevalier
South
20. Name of Andrew Nicholson’s horse for the 2012 Olympics. (5)
Unitec
Campus
25. The V20°R-DCdO image of the skull utilized to evaluate nasal chambers is frequently
called the_____- _____ VD. (4 / 5)
26. The _____ skyline projection of the skull can be used to evaluate frontal sinus pathology. (11)
d
hR
o rt
Gr
ea
tN
24. A focal area of increased capacity within the long bone of a young adult German
Shepherd is a feature of? (11)
Gate 2
97
VSG
Farm
ort
at N
h Rd
ay
torw
Mo
s tern
City
We
nd
h
a
t
l
k
N
Au c
Chamberlain
Park Golf Course
n Rd
22. Isolated piece of bone in osteomyelitis surrounded by a zone of radiolucency on a
radiograph. (10)
23. An indistinct zone of _____is a feature more commonly seen in primary bone neoplasia. (10)
Carringto
21. The name of a 1930s designed Taupo fly fishing lure, think Royal. Mrs._____ (7)
Gre
Rd
Gate 3
Directions from Auckland City:
Head west on North Western M’way
(approx 5km), exit for Great North Rd.
Turn right at lights (under M’way).
Turn right at Carrington Road.
VSG is 700m on right.
27. Contrast agent used in myelography. (7)
28. Serpent-like filling defect on the floor of C2 on myelography is due to the _____artery. (7)
29. The digits are a predilection site for metastasis from feline primary _____neoplasia. (9)
30. _____ effusion is commonly associated with lung lobe torsion. (7)
31. What is the most common cardiac neoplastic disease process affecting the feline heart? (8)
32. The most common heart base neoplasm is _____. (12)
33. A condition which results in a double wall sign of the trachea in thoracic radiographs. (17)
34. Which city is going to hold the WSAVA conference in 2013? (8)
THE NEXT STEP
PAGE 8
To enter please fax, email or post
answers to VSG by 31st October 2012.
All correct entries go into the draw for a
medical text book or a bottle of Dom Perignon.
Answers available at www.vsg.co.nz after
1 November 2012.
The winner of the Medicine Crossword in
the July issue was Dr Melissa McMiken of
Franklin Vets, Auckland.